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Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Kerry E Uebel12, Lara R Fairall13*, Dingie HCJ van Rensburg4, Willie F Mollentze2, Max O Bachmann5, Simon Lewin67, Merrick Zwarenstein1089, Christopher J Colvin11, Daniella Georgeu1, Pat Mayers12, Gill M Faris1, Carl Lombard13 and Eric D Bateman1415

Author Affiliations

1 Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa

2 Department of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

3 Department of Medicine, University of Cape Town, Cape Town, South Africa

4 Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa

5 School of Medicine Health Policy and Practice, University of East Anglia, Norwich, UK

6 Norwegian Knowledge Centre for the Health Services, Oslo, Norway

7 Health Systems Research Unit, Medical Research Council of South Africa, Cape Town, South Africa

8 Sunnybrook Research Institute and Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada

9 IHCAR, Karolinska Institute, Stockholm, Sweden

10 Faculty of Medicine, University of Stellenbosch, Tygerberg, South Africa

11 Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

12 Division of Nursing and Midwifery, School of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

13 Biostatistics Unit, Medical Research Council, Cape Town, South Africa

14 Department of Respiratory Medicine, University of Cape Town, Cape Town, South Africa

15 University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa

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Implementation Science 2011, 6:86  doi:10.1186/1748-5908-6-86

Published: 2 August 2011

Abstract

Background

Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial.

Methods: Developing the intervention

The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services.

Results: Components of the intervention

The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process.

Discussion

Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.

The STRETCH trial is registered with Current Control Trials ISRCTN46836853.